Given current technological trends, the number and magnitude of changes brought about by IT and its potential applications will only increase. We are not far from the day when computers will permeate virtually everything we do, from how we read our morning newspapers to how we make treatment decisions for our patients.¹⁰

Within the next five years, experts foresee the commercial availability of electronic paper (paper that functions like a very high-resolution computer screen), a vast array of special-purpose computing appliances, autonomous software agents that enter into transactions on our behalf, an almost ubiquitous high-capacity networking infrastructure and personal digital assistants that rival current desktop computers in performance.

How can these technological advances be made most useful for dental practice, research and education? Technological innovation for the health care professions originates from a number of sources, such as the commercial market, research and educational institutions, and people. While companies collectively engage in research and development of significant scale and scope, their interests primarily are driven by the profit motive. Most innovations are pursued because they are expected to make money. Other projects, which may be more important or significant but are not deemed as profitable, receive scant attention and resources. One example is the American National Standards Institute, or ANSI, standard digital imaging and communications in medicine, or DICOM, which defines a format for storage and exchange of digital images, including radiographic and visible-light images. DICOM is the almost universal standard for managing images in clinical medicine.¹¹ Until recently, however, digital dental radiology system vendors have been slow to implement DICOM. One reason has been that dental extensions for DICOM are relatively new, and many vendors may not realize the benefits of implementing DICOM. But more importantly, DICOM allows dentists to combine imaging devices and software from several vendors and, thus, removes the "lock-in" that vendors of proprietary systems have enjoyed so far.

The commercial market has brought many innovations to the dental profession. But it is not likely to address many fundamental problems—such as controlled vocabularies, open standards for exchanging patient information among practitioners, quality assurance for patient outcomes and mechanisms to represent dental knowledge—any time soon. While academic and other institutions are working on some of these issues, one obstacle to progress is the fact that the field of dental informatics is not very mature.

Dental informatics combines dentistry and several research disciplines, such as computer science and telecommunications. Because it is new, there is confusion relative to its definition, goals, opportunities and achievements. Therefore, we wrote this article to answer several questions: What is dental informatics? What are its goals? Is it a discipline? What are its opportunities and challenges? How can the practitioner get involved and stay up to date? We wrote this article to stimulate interest in this emerging field and help readers understand how dental informatics can become a cornerstone of dental practice.

	WHAT IS DENTAL INFORMATICS?

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According to Merriam-Webster’s Collegiate Dictionary, informatics is derived from the term "information science," which is the collection, classification, storage, retrieval and dissemination of recorded knowledge treated both as a pure and applied science.¹² When applied to a specific domain, such as medicine, nursing or dentistry, information science becomes "informatics." Existing definitions of medical informatics^13,14 share several common elements^15,16 (Table 1).

A common misconception is that informatics is the same as IT.¹⁸ Informatics is focused primarily on research, development and evaluation of information models and computing applications. IT, on the other hand, is concerned with the implementation and application of computer technology and telecommunications. Despite the larger conceptual division, limited areas of overlap between informatics and IT exist, such as custom development of software and evaluation of implemented systems.

Dental informatics can be considered a specialty of medical informatics. A number of models, methods and applications can be shared, transferred or both between the two disciplines. For instance, the National Library of Medicine’s, or NLM’s, MEDLINE is the world’s largest biomedical literature database and is equally applicable to all health care disciplines. The same applies to GenBank, a database of gene and protein sequence information to which researchers from several domains contribute. Methods for building expert and decision-support systems, such as neural and Bayesian networks, can be applied across disciplines.¹⁹ Despite much common ground, there also are many aspects that set those informatics domains apart. For instance, most design work that informs the development of computer-based medical records simply is not applicable for computer-based dental records. Dentists collect, display and analyze data differently than do their medical counterparts. While the general medical and medication histories collected by both physicians and dentists share many common elements, the dental history and the oral health status have no equivalent in medicine. As a consequence, developing, implementing and evaluating complete computer-based dental records is both a challenge and an opportunity for dental informatics, as are many other domain-specific aspects.

	WHAT ARE DENTAL INFORMATICS’ PRACTICAL GOALS?

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The main goal of dental informatics is to improve patient outcomes. Thus, the discipline must support and improve diagnosis, treatment and prevention of disease and traumatic injury; relieve pain; and preserve and improve oral health. A secondary goal is to make the delivery of dental care more efficient; for example, by maintaining or improving cost-benefit ratios. Dental informatics also must support research and education, and improvements in these areas should, and often do, translate into improved patient care.

Developing, implementing and evaluating complete computer-based dental records is both a challenge and an opportunity for dental informatics.

Informatics is key in helping practitioners solve clinical problems and keep current. Most educational programs still subscribe to the philosophy that everything dentists need to know can be learned in dental school. The trend toward problem-based learning and the development of critical-thinking skills tells a different story.^20–22 Dentists must be as familiar with the problem-solving process as they are with the problem domain itself. Computers can help practitioners maintain their continuing competency, and many dentists already are using computers to keep abreast of new developments.^23,24

Many examples of developments in dental informatics that have helped improve patient outcomes (or have the potential to do so if widely used), education and research can be cited. Table 2 offers a description of selected computer applications.^19,25–43 The list is not inclusive, but rather provides an overview of the breadth and depth of existing applications.

	IS DENTAL INFORMATICS A DISCIPLINE?

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– a core of people who conduct research and publish in the discipline;

– an identifiable body of literature: books, journals and other publications;

– professional societies and related activities, such as meetings and conferences;

– educational programs leading to a certificate or advanced degree;

– funded research programs.

A core of people who conduct and publish research in dental informatics exists. An informal review of the literature showed that since 1965 approximately 3,500 authors have published about 2,200 articles related to dental informatics and computer applications in dentistry in about 420 journals and conference proceedings. Journals with significant numbers of informatics-related articles include Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics; JADA; Dentomaxillofacial Radiology; the Journal of Dental Education; and the British Dental Journal. The Journal of the American Medical Informatics Association and the International Journal of Computerized Dentistry are more narrowly focused. The first book on dental informatics was written in 1992 and provides a conceptual overview of the field.⁴⁴ Other books, such as "The Global Village of Dentistry"⁴⁵ and "Imaging in Esthetic Dentistry"⁴⁶ provide more detailed looks at some application areas.

Currently, dental informatics has no mainstream journal of its own, the emergence of special-purpose journals (such as the Journal of Computerized Dentistry) notwithstanding. This is appropriate considering that dental informatics is in the early stages of development and that, at this time, it is more important to educate a broad audience about the possibilities of dental informatics than to provide a specialized forum for dental informatics researchers. Over the long term, however, the development of a dedicated, international and multidisciplinary dental informatics journal should be considered.

Currently, dental informatics has no dedicated professional society. Rather, its activities are integrated with those of several existing associations, such as the American Dental Education Association, or ADEA; the ADA; and the American Medical Informatics Association, or AMIA. In most cases, a section or special interest group of an association provides a forum for exchange between members. Specialized conferences, such as the Conference on Computers in Clinical Dentistry, those sponsored by ADEA, the Consortium for Clinical Information Systems, and the Conference on Computers in Dental Education and Practice have been held in the past. Up until now, these conferences have been arranged on an ad hoc basis, and none has developed into a stable, widely accepted scientific forum.

The first educational programs leading to advanced degrees in dental informatics were created in 1996 in response to a request for applications issued by the National Institute of Dental and Craniofacial Research, or NIDCR, in cooperation with NLM. A program at Columbia University and a joint program offered by the University of Pittsburgh and Temple University offer master’s degrees through three-year and two-year programs, respectively. The philosophy of both training programs is grounded in the belief that dental informatics is derived from medical informatics rather than a separate discipline.⁴⁷ Thus, trainees complete a generalist education in medical informatics and specialize in dental informatics. The programs graduated their first trainees in 2000.

Anecdotal evidence suggests that dental informatics research receives only limited third-party funding, such as from the government, the military, foundations and companies. NIDCR and NLM have funded very few grant applications in dental informatics, and some universities have been and are receiving limited corporate support. In contrast, programs sponsored by the European Union have resulted in significant funding in dental informatics research in Europe. Much of the research in dental informatics at this time is conducted as "unfunded" research by faculty at dental schools and universities around the world.

It is instructive to compare dental informatics to its parent, medical informatics. The medical informatics research community is extremely active. Medical informatics has its own literature that is segmented into topics such as biomedical engineering, biomedical computing, decision support and education.⁴⁸ Major informatics journals, such as MD Computing and the Journal of the American Medical Informatics Association, have existed since the early 1990s, and approximately 140 books about medical informatics have been published. Twelve medical informatics training programs funded by NLM exist, and approximately 30 of the 150 medical schools in the United States have a department or section of medical informatics. Conferences such as Towards Electronic Patient Records and the AMIA’s fall symposium attract several thousand participants each year. Medical informatics research is funded by programs of significant scale and scope at NLM, the National Cancer Institute and the National Science Foundation, as well as by corporations and foundations.

Dental informatics is a nascent discipline. To what degree it can mature successfully depends on its ability to take advantage of opportunities and overcome some significant challenges.

	OPPORTUNITIES AND CHALLENGES

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Dentistry is an information-intensive activity, and informatics by its very nature supports such activities well. IT already has significantly improved our ability to store, access, manage, filter and apply information. When one considers what progress has been made in a myriad of aspects of human life, it is not difficult to envision how dentistry may be transformed by becoming informatics-based.¹⁶ Ultimately, informatics done well simply will let us concentrate on our jobs as dental professionals by improving and maintaining the oral health, and consequently the general health, of our patients. These new and powerful technologies will bring cultural changes to the dental profession itself. The following are some opportunities and challenges that informatics places before us.

Longitudinal, lifetime, comprehensive and patient-centered dental records. Dentistry is still largely a cottage industry. This situation expresses itself in the minimal degree to which patient information is shared. Patient-centered, rather than practice-centered, dental records can eliminate duplicate information gathering, provide a rich context through access to prior diagnostic and treatment records, and allow the practitioner to concentrate on the problem at hand. The book "Futurize Your Enterprise"¹ contains an excellent vision of how patient-centered medical records can improve health care. Several computer system vendors offer precursors to such systems already today.⁴⁹

Universally accessible patient records that ensure privacy and confidentiality. As an increasing portion of patient-related information is stored and transmitted digitally, dental informatics has the responsibility to develop, implement and monitor measures to keep it private. While no system is perfectly secure, a balance between privacy and access must be found.^50,51

Significant reduction of practice management and administrative overhead. A significant portion of health care expenditures go toward administration. One of the greatest sources of inefficiency has been the lack of shared information by health care buyers, sellers and consumers.⁵² Well-integrated information systems can reduce this overhead significantly, through measures from autonomous supply ordering to automated scheduling, billing and recall.

Clinical care based on empirically determined best practices. Most patients in industrialized countries already enjoy very high standards of care. However, large variations in diagnosis and treatment decisions still exist.^53,54 As more patients become aware of the standard of care, dentists will be forced to prove the quality of their care. While few dental treatments are based on definitive clinical evidence obtained through randomized clinical trials, outcomes data aggregated over large numbers of practices and patients can help identify best practices. Since many patients use the Internet to access health-related information, valid and reliable information needs to be available and recognizable as such.⁵⁵

Well-integrated information systems can reduce overhead significantly, through measures from autonomous supply ordering to automated scheduling, billing and recall.

How can the dental profession take advantage of these opportunities? A positive circumstance is that dentistry as a profession is relatively unified. The majority of U.S. dentists are members of the ADA. The ADA and other dental organizations, such as the Academy of General Dentistry and the American College of Dentists, provide common ground and political clout on many important issues. Yet success in realizing the present opportunities rests on significant innovation, research and development in informatics that most likely will not come from central organizations.

While it may seem difficult to forge a common vision for informatics within the dental profession, it is not impossible. One attempt at crafting a long-term strategy is the development of standards related to dental informatics through the newly formed, ANSI-accredited Standards Committee on Dental Informatics, or SCDI, which is administered by the ADA, as well as its predecessor the ASC MD 156 Task Group on Dental Informatics. Unfortunately, after seven years of work, this effort has achieved little. Tangible products that have been developed include the Concept Model for the Standard Computer-Based Oral Health Record⁵⁶ and the Guidelines for the Design of Educational Software.⁵⁷ Neither of these efforts has evolved into a widely accepted and applied standard, but progress may improve based on the recent formalization of the SCDI.

Another challenge is to increase the quality and quantity of dental informatics research. The standards for investigation and scientific inquiry in new disciplines develop over time, and dental informatics is no exception. What passes for research and what does not is a subject of periodic discussion in medical informatics even today.^15,58 The scarcity of people formally trained in research methods and approaches and the dearth of interdisciplinary teams that can solve complex research questions constrains the volume and quality of research output. Support for dental informatics research from grants, contracts and funding agencies such as NIDCR or NLM is minute. The problem, however, is two-sided. The lack of qualified investigators in dental informatics results in a scarcity of fundable research proposals. Funding agencies, on the other hand, may not view dental informatics as a programmatic priority if demand for research funding is not apparent.

Dentistry is a relatively small segment of the health care system. Thus, many companies are hesitant to invest in research and development because the potential payoff is constrained by the small size of the market. Network externalities also are a significant deterrent to investment.⁵⁹ Products or services, such as the telephone, that become more valuable as more people use them are said to benefit from network externalities. For instance, when only a few practices can exchange patient information using computer-based patient records, or CPRs, the collective benefit is small. When most practices use such interoperable CPRs, however, the collective benefit is large. Globalization may improve this situation because it increases potential markets.

The growth of dental informatics also is hampered because many of its benefits are hard to measure, and achieving them requires significant upfront and ongoing investments. For instance, the quantifiable benefits of a computer system for billing and electronic claims submission include time and money saved in preparing claims, reduced claim and payment turnaround, and improved management of accounts receivable. The advantages of installing a CPR, on the other hand, are much harder to define and measure. Evaluating the return on investment, however, is fraught with difficulties not only in dental informatics. Nobel Prize–winning economist Robert Solow said that we see computers everywhere except in the productivity statistics. Productivity growth has slowed every decade from the 1960s until the mid-1990s, while investments in IT have grown dramatically. This phenomenon has been termed the "productivity paradox." However, the dramatic contribution of computers to the rising productivity since 1995 may indicate that we have reached a turning point.⁶⁰ Since health care in general and dentistry in particular still lag in the use of computers, most benefits still are to come.

The growth of dental informatics is hampered, in part, because many of its benefits are hard to measure, and achieving them requires significant upfront and ongoing investments.

The current situation simply may be symptomatic of a profession finding its way in informatics. An encouraging sign is the significant and increasing interest of many influential stakeholders in dentistry. Hopefully, this interest can be channeled into concerted action that benefits all of dentistry. Success, however, also is predicated on the level of involvement of each practitioner. The next section highlights some opportunities.

	HOW CAN YOU GET INVOLVED IN DENTAL INFORMATICS?

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Getting involved in and staying up to date on dental informatics is not as easy as joining a professional society and subscribing to its journal. There are, however, a few options.

Articles on dental informatics in major dental journals. Journals in which articles about dental informatics appear periodically include JADA, the Journal of Dental Education, Quintessence International and the Journal of Computerized Dentistry. The Journal of the American Medical Informatics Association, MD Computing, the Journal of the American Medical Association and the British Medical Journal are good sources for keeping up with general medical informatics developments.

Meetings and conferences. Venues for informatics-related topics are the ADA’s technology days, the ADEA’s annual session and AMIA’s fall symposium.

Standards activities, society activities, university committees and vendor focus groups. The ADA-administered SCDI is an excellent way for dentists to get involved in setting the standards for tomorrow’s IT applications in dentistry. Local and regional dental societies, universities and vendors increasingly maintain committees or advisory boards to help shape their strategies for IT, and they often offer interested dentists a chance to get involved.

Computer courses. Colleges and universities offer introductory and advanced courses in information systems, programming and databases. Many companies offer courses on specific applications, such as desktop productivity and graphics programs. Programs for bachelor’s or master’s degrees in a variety of computer-related areas also are available, and some of the necessary courses can be taken through distance learning programs.

Communities. The Dental Informatics Section of ADEA and the Dental Informatics Working Group of AMIA allow people interested in dental informatics to network. Both groups maintain Internet discussion lists that include members from all over the world. Joining these communities is free for members of the respective organizations.

Dental informatics degree programs. Two dedicated postgraduate programs in dental informatics currently exist.^61,62 Both are appropriate for people interested in having a research career in dental informatics. The opportunities available today make this an option particularly attractive for dentists who would like to participate in shaping the development of dental informatics. It is safe to assume that the sources of information and the opportunities for interested dentists to get involved will only multiply in the future.

	CONCLUSION

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"There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things." Niccolò Machiavelli’s words describe the challenge to dental informatics well. Computer technology has reshaped our lives already. The question is to what degree it will reshape dentistry. The ubiquitous reach of today’s computer networks presages significant change: dentistry is not an isolated province of health care anymore. We are now, more than ever, connected to a larger system of stakeholders, regulations, expectations, accountability and risk.

The road to clinical practice that is invisibly and seamlessly supported by informatics will be nothing short of arduous. Putting the theories and concepts of informatics into practice requires significant effort and investment. Many projects on this road will fail. Dentistry, however, should learn from the failures as much as it does from the successes. Only then will we realize the promise of informatics.

View larger version (134K): [in this window] [in a new window]   Dr. Schleyer is an associate professor and the chair, Department of Dental Informatics, Temple University School of Dentistry, 3223 N. Broad St., TU 600-00, Philadelphia, Pa. 19140, e-mail "Titus@DENTAL.Temple.edu". Address reprint requests to Dr. Schleyer.